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Mitral Valve Repair for Rheumatic Disease

Wednesday, March 24, 2010

STSA Surgical Motion Picture 2009 Annual Meeting

Most rheumatic mitral valves have undergone replacement in recent years, but replacement mortality remains significant at a time when repair mortality is approaching zero. Therefore, an effort was made to increase repair rates and efficacy in a single surgeon series of patients having operation for rheumatic mitral valve disease. All 14 patients encountered with rheumatic mitral valves over the past 5 years have undergone successful repair. One had pure stenosis, 6 had pure regurgitation, and 7 had advanced forms of mixed stenosis and regurgitation. Because posterior leaflet retraction is such a prominent feature of rheumatic disease, a gluteraldehyde-fixed autologous pericardial patch was sutured into the posterior leaflet in all. In 9 patients, thickened and scarred chords to the anterior leaflet (either obstructing full opening or tethering closure) were resected, extended commissurotomies were performed, an anterior leaflet "hinge" mechanism was restored, and the anterior leaflet was reattached to the papillary muscles using Gore-Tex artificial chords (J Heart Valve Dis 2008;17:614-619). All 14 patients had full rigid ring annuloplasties. Every patient recovered uneventfully and without major complications. Postoperatively, all had negligible gradients and no residual leak. The first patient (with mixed stenosis and regurgitation) was restudied with transesophageal echo after 4 years, and continued to have good valve function. One patient underwent re-repair 1-year postoperatively for endocarditis. Operative views and transesophageal echocardiograms from 4 of these patients are shown in this video. In conclusion, combinations of posterior leaflet pericardial patching, anterior leaflet chordal resection/Gore Tex artificial chordal replacement, extended commissurotomy, and full ring annuloplasty allows excellent repair of rheumatic valves over the full range of pathologies. Early and intermediate-term results seem quite satisfactory. Continued application and development of repair techniques for rheumatic mitral disease seem indicated.

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